MEDICARE: DR. ALVIN J STOSICH MD, DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	6434136-9925	UT
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	6395	NE
3	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	6434136-1205	UT

General Provider Information

NPI Number	:	1689795114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALVIN J STOSICH MD, DDS

Provider Business Mailing Address
First Line	:	6268 S 900 E
Second Line	:	STE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2497
Country	:	US
Telephone Number	:	801-566-5117
Fax Number	:	801-566-5119

Provider Business Practice Location Address
First Line	:	6268 S 900 E
Second Line	:	STE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2497
Country	:	US
Telephone Number	:	801-566-5117
Fax Number	:	801-566-5119

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	11/01/2021

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